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Phone Calls Boost Cancer Screening

Low-income women got more of the cancer screenings they needed when encouraged and assisted by trained "care managers" who called them on the phone, researchers report in Annals of Internal Medicine. The care managers talked to the women about why screening was important, urged them to get tests they'd missed, and helped them schedule appointments.

The study involved 1,413 women who were regular patients at 1 of 11 community and migrant health centers in New York City. It was led by Allen Dietrich, MD, of Dartmouth Medical School and the Norris Cotton Cancer Center, and Jonathan N. Tobin, PhD, of Clinical Directors Network, Inc., a clinical research network and clinician education organization.

The women were primarily from low-income neighborhoods. More than 78% were enrolled in Medicaid and more than 60% listed Spanish as their primary language. All were overdue for at least one cancer screening test, including mammograms, Pap tests, or colorectal screening, according to their medical records.

The women were randomly divided into 2 groups at the beginning of the study. All of the women got a brochure with information on recommended cancer screening tests, and women in the control group got 1 phone call advising them to get the tests they needed.

Women in the intervention group, though, received a series of phone calls (about 4 on average) from trained care managers who acted like patient navigators, helping them to understand screening and work through problems that might be keeping them from getting needed tests.

For instance, if a woman said her doctor hadn't talked with her about screening, the care manager asked the doctor to send her a letter telling her which tests she needed. If a woman said she couldn't communicate well with her doctor about screening, the care manager sent her a card listing the screening tests she needed in English and Spanish. The woman could take this card back to her doctor to get the ball rolling.

Over 18 months, screening rates for breast, cervical, and colorectal cancers each went up significantly in the intervention group compared to the control group.

Dietrich called the results "very gratifying," especially considering that screening rates in both groups at the beginning of the study were already quite high for mammograms and Pap tests.

This isn't the first study to try phone calls as a way of encouraging people to get screened. The approach is promising, said Richard C. Wender, MD, president-elect of the American Cancer Society and a member of the ACS board of directors. He is also chair of the Department of Family and Community Medicine at Jefferson Medical College of Thomas Jefferson University.

"There are a lot of barriers to preventive care and just relying on the clinicians alone to do this is difficult," said Wender, who was not involved with the current study but is familiar with the prior work of Dietrich and his colleagues. "If you depend just on the memory of the physician at the time of the visit to remember to order all the things they're supposed to order, it's less likely to happen."

Dietrich and Tobin say other health care organizations could start similar programs with a little legwork. For instance, they need to be sure they can actually provide the screening tests they encourage patients to get.

"It seems to me that before a place made an investment in this kind of program, they'd want to be able to respond to the woman's request," said Dietrich. "That makes sense because we'd be doing harm if we encouraged women to get screening and then sent them to places that couldn't respond."

And they'd need to make an investment in the care managers.

"Implementing this method requires the addition of new staff who are trained to be prevention care managers, or it means reducing their current workload to create enough time to undertake effectively this new set of responsibilities," Tobin explained.

The challenge, of course, is finding the money to do this. But Tobin stressed that this program is relatively low-cost. The training program for the care managers is designed for people at the level of a medical assistant, not for higher-paid registered nurses or physicians' assistants.

Wender agreed that finding resources to pay for these types of programs is a problem. But it's one that should be addressed because prevention pays off.

"This could be duplicated in multiple settings and it should be," he said. "This is the approach we need."

Citation: "Telephone Care Management to Improve Cancer Screening Among Low-Income Women." Published in the April 18, 2006, Annals of Internal Medicine (Vol. 144, No. 8: 563-571). First author: Allen J. Dietrich, MD, Norris Cotton Cancer Center and Dartmouth Medical School.